Trans Medical Care

A transgender woman has become the first in the world to breastfeed her baby after undergoing hormone treatment. The 30-year-old woman, who hasn’t been named, approached Tamar Reisman and Zil Goldstein from the Mount Sinai Centre for Transgender Medicine and Surgery in New York.

She explained that her partner was pregnant but didn’t want to breastfeed, so she was hoping that she could take on the role when their baby was born. The patient had been following a feminising hormone regime since 2011.

However, she hadn’t undergone any gender-affirming surgeries such as breast augmentation, orchiectomy or vaginoplasty, Reisman and Goldstein stated in a case report published in journal Transgender Health.

Reisman and Goldstein, a nurse practitioner and a programme manager respectively, enabled the transgender woman to breastfeed her baby for the first six weeks of its life by inducing lactation.READ ARTICLE

It’s pretty well known that prostate cancer is a disease that should be on every man’s radar. After all, it's the most common cancer among American men, and an estimated 161,360 new cases of the disease are expected to be diagnosed this year, according to the American Cancer Society. But things are a little more muddled for transgender women—and experts say that trans women need to be aware of their prostate cancer risk.

Basically, if you have a prostate, you're at risk of developing prostate cancer.

Even people who have undergone gender-affirming surgery will typically still have a prostate, Zil Goldstein, assistant professor of medical education and program director for the Center for Transgender Medicine and Surgery at Mount Sinai Health System, tells SELF.

Prostate cancer can and does happen to transgender women. A 2013 case study published in the Canadian Urological Association Journal, for example, reports the case of a transgender woman who was diagnosed with metastatic prostate cancer (meaning, it had spread beyond her prostate to other parts of her body), 31 years after she transitioned. Another case study published in JAMA tells the story of a transgender woman who was diagnosed with prostate cancer 41 years after her transition.

According to the University of California, San Francisco Center of Excellence for Transgender Health, there have been cases of prostate cancer in transgender women with a variety of surgical histories and hormone therapies, meaning it's hard to say that any one surgery or hormone therapy would obliterate your risk. However, most cases of prostate cancer in transgender women have involved people who started hormone therapy later in life.

“We don’t have any data specific to transgender women,” Goldstein says. “For any given person with a prostate, there’s an 11.6 percent chance that they’ll develop prostate cancer in their lifetime.” If you’re a transgender woman, that number could apply to you; but it depends on what your transition has included.

For transgender women who have had gender-affirming surgery or are on hormone therapy, the risk of prostate cancer seems to be very low.

“But if you have transgender women who haven’t been on hormones, then their prostate cancer risk is the same as cisgender men,” Asa Radix, M.D., M.P.H., F.A.C.P., director of research and education at Callen-Lorde Community Health Center, tells SELF. “It really is about whether or not they’re having interventions.”

Prostate cancer treatment for cisgender men typically involves testosterone blockers and estrogen, which is common for transgender women on hormone therapy, Dr. Radix points out. “Many transgender women already have prevention treatment on board,” he says. “That’s probably why the rates are so low.”

So, should you be screened for prostate cancer?

First, let's start with the screening recommendations for cisgender men. According to the American Cancer Society, men should not be routinely screened for prostate cancer until they have a conversation with their doctor about their personal risks and the potential for uncertainty with results. Men who proceed with screening may be given a prostate-specific antigen (PSA) blood test (which can indicate an abnormal cell count in the prostate gland) and/or a digital rectal exam.

The screening process is similar for transgender women. It’s not currently recommended that doctors regularly screen transgender women for prostate cancer, Dr. Radix says; but doctors are encouraged to have a conversation with patients about their family history of prostate cancer and any symptoms, which can include burning during urination, trouble urinating, and pelvic discomfort. If a transgender woman has these symptoms or a strong family history of the disease, a prostate exam may be warranted, which can be done rectally or through a vaginal exam. Transgender women can also have a PSA test. However, Goldstein says this number may be lower in transgender women who are on hormone therapy, so doctors are encouraged to double the number to get a more accurate figure.

If you still have a prostate, Dr. Radix says it’s important to remember that you may still be at risk for prostate cancer, which means that you should talk to your doctor about screening. You can search for LGBT-friendly doctors at places like: GLMA.org, WPATH.org, or trans-health.com.

INTRODUCTION:Transsexuality, also termed 'Gender Dysphoria' is now reaching the point of being reasonably well understood, though many myths and general foolishness about the subject still abound. This document concerns the classic definition of transsexuality, as defined by Benjamin, Money, Green, and so forth. Intersexuality and transgenderism will not be addressed other than obliquely.IN A NUTSHELL: This is about standard, classical transsexuality.

SUMMARY DEFINITION:Gender Dysphoria, literally a misery with regard to gender, is the condition of being in a state of conflict between gender and physical sex.A transsexual is a person in which the sex-related structures of the brain that define gender identity are exactly opposite the physical sex organs of the body.Put even more simply, a transsexual is a mind that is literally, physically, trapped in a body of the opposite sex.IN A NUTSHELL: Transsexuality means having the wrong body for the gender one really is.

GRAND OVERVIEW:Gender and Sex are very separate things, though the terms are often considered interchangeable by the less aware. Sex is physical form and function while Gender is a component of identity. There can be considered to be some legitimate overlap in that the brain is structured in many sex-differentiated ways, and the brain is the seat of identity. However, with regard to the dilemma of the transsexual, the difference between sex and gender are at the very core of the issue.A transsexual person, born to all appearance within a given physical sex, is aware of being of a gender opposite to that physical sex. This conflict, between gender identity and physical sex, is almost always manifest from earliest awareness, and is the cause of enormous suffering. It is common for transsexuals to be aware of their condition at preschool ages.This agony can and does lead to self destruction unless treated. The incredible difficulties that surround achieving treatment are themselves often agonizing, the sum total of which can play havoc with the lives of the gender dysphoric. Indeed, it is apparent that some fifty percent of transsexuals die by age 30, usually by their own hand.The standard treatment for a diagnosis of transsexualityis to reassign the transsexual to a physical sex congruent with their gender identity, a process involving the administration of appropriate hormones and surgery. The success of this treatment is exceedingly high, and many transsexuals go on to live successful lives.READ ARTICLE

Some children are born with gender variations that have previously been met with silence and stigma and often unnecessary surgery. Now there is growing awareness among medical professionals so that people can grow up in a way they want to, rather than conforming to gender stereotypes.

At 13-years-old, Sean Saifa Wall was admitted to hospital with pain in his groin. He says that he was given very little information about what might be causing it, and doctors didn’t discuss different options for treatment with him. He was told that his testes had to be removed immediately.

“I remember before surgery… I asked the nurse what was going on, and [she] was saying that I have these gonads that need to be removed. I’m 13 – I don’t know what gonads are.” The nurse told Saifa that it was because “they’re not good”. To Saifa it sounded logical: “If it’s not good and it’s in my body, it probably should be taken out.”

But today he still doesn’t know what, if anything, was dangerous about keeping his testes or what was causing the pain. Not too long after the surgery, he remembers one conversation in particular: “The surgeon was talking about how he wanted to create a vagina. The way he described it… it sounded barbaric.” Saifa says, recalling that he was sat in the surgeon’s room in horror. “My mum was to my right… and I was probably turning green, and [she] looked at me and said, ‘Do you want to go through with this?’ ”

Saifa immediately said no. “I remember the surgeon was saying, ‘We’re going to shave down the clitoris.’ And I was like, this all sounds painful and horrible. I think, in that second, that one moment, that was what spared me from genital surgery.”

As a child growing up between New York and North Carolina in the late 1970s and early 1980s, Saifa was at the cusp of a change in thinking about the medical management of intersex conditions in the US. He is one of seven living relatives with the same intersex condition. Three of these relatives identify as female, having undergone surgeries in childhood to remove their testes.READ ARTICLE

Some children insist, from the moment they can speak, that they are not the gender indicated by their biological sex. So where does this knowledge reside? And is it possible to discern a genetic or anatomical basis for transgender identity? Exploration of these questions is relatively new, but there is a bit of evidence for a genetic basis. Identical twins are somewhat more likely than fraternal twins to both be trans.

Male and female brains are, on average, slightly different in structure, although there is tremendous individual variability. Several studies have looked for signs that transgender people have brains more similar to their experienced gender. Spanish investigators—led by psychobiologist Antonio Guillamon of the National Distance Education University in Madrid and neuropsychologist Carme Junqué Plaja of the University of Barcelona—used MRI to examine the brains of 24 female-to-males and 18 male-to-females—both before and after treatment with cross-sex hormones. Their results, published in 2013, showed that even before treatment the brain structures of the trans people were more similar in some respects to the brains of their experienced gender than those of their natal gender. For example, the female-to-male subjects had relatively thin subcortical areas (these areas tend to be thinner in men than in women). Male-to-female subjects tended to have thinner cortical regions in the right hemisphere, which is characteristic of a female brain. (Such differences became more pronounced after treatment.)

Antonio Guillamon‘s team at the National University of Distance Education in Madrid, Spain, think they have found a better way to spot a transsexual brain. In a study due to be published next month, the team ran MRI scans on the brains of 18 female-to-male transsexual people who’d had no treatment and compared them with those of 24 males and 19 females.

They found significant differences between male and female brains in four regions of white matter – and the female-to-male transsexual people had white matter in these regions that resembled a male brain (Journal of Psychiatric Research, DOI: 10.1016/j.jpsychires.2010.05.006). “It’s the first time it has been shown that the brains of female-to-male transsexual people are masculinised,” Guillamon says.

In a separate study, the team used the same technique to compare white matter in 18 male-to-female transsexual people with that in 19 males and 19 females. Surprisingly, in each transsexual person’s brain the structure of the white matter in the four regions was halfway between that of the males and females (Journal of Psychiatric Research, DOI: 10.1016/j.jpsychires.2010.11.007). “Their brains are not completely masculinised and not completely feminised, but they still feel female,” says Guillamon.

Several published studies in the medical literature on psycho-neuro-endocrinology have examined the hypothesis that prenatal exposure to estrogens (including Diethylstilbestrol) may cause significant developmental impact on sexual differentiation of the brain, and on subsequent behavioural and gender identity development in exposed males and females. There is significant evidence linking prenatal hormonal influences on gender identity and transsexual development.

There is a possible connection between DES exposure and gender variance

In 1999, Dr. Scott Kerlin (founder of the DES Sons International Network) began researching the effects of Di-Ethyl Stilbestrol®on the health of genetic maleswho had been exposed prenatally. A substantial amount of research had been done on women who had been exposed but relatively little had been done on men and DES sons. When it became apparent that a significant portion of his research group were eithertranssexual, transgendered or intersexed, he began to explore the possibility of a connection between prenatal DES exposure and gender variance. Dr. Kerlin is not the first researcher to note a correlation between DES exposure and feminized behaviour in genetic males; studies go back as far as 1973. However, Dr. Kerlin has delved much deeper than those who came before.

Dr. Dana Beyer is the medical advisor and web manager of the DES Sons International Network, on the effects of endocrine disrupting compounds such as Diethylstilbestrol, DDT, phthalates and bisphenol A, on human sexuality and reproduction, as well as providing personal support and mentoring. In 2005 she presented a breakthrough paper, with her colleagues Dr. Scott Kerlin and Dr. Milton Diamond, to the International Behavioural Development Symposium, delineating the impact Di-Ethyl Stilbestrol® has had in causing intersex and gender variations in human beings.

I understand this is a sensitive and controversial matter but I feel it is important to bring this issue to light and break the wall of silence around what is still nowadays considered as “taboo”. I would like to invite all DES exposed individuals who have a knowledge of DES exposure and gender identity either through research or personal experience to share their comments and stories.

Testosterone and estrogen are the hormones associated with gender. The average male, female and everyone in between have bodies that run on and need both. Today we are going to explore estrogen and the effects of it on the transgender female. Please note before we proceed that if you are currently undergoing or thinking of undergoing hormone replacement therapy with estrogen that we strongly recommend you do so under the care of a physician. There can be many dangers and health risks if estrogen is not administered and monitored properly.

Hormone Replacement Therapy with estrogen is the process of administering the hormone to “male to female” transgender patients in order to induce and maintain the development of female secondary sex characteristics. Though estrogen cannot reverse the effects of puberty, HRT with estrogen can help develop female characteristics and make a patient look more like the female gender they identify with. It causes significant social and psychological changes while affecting your mood, energy, appearance and overall health. Though not a full cure it is very effective at treating patients with gender dysphoria. Estrogen can be administered by injections, pills, patches and subdermal pellet implants.

Both testosterone and estrogen are needed for healthy bone and to prevent osteoporosis. Estrogen is the predominant sex hormone that slows bone loss. The hips will rotate slightly forward due to changes in the tendons so hip discomfort is not uncommon. If estrogen therapy is conducted prior to the pelvis ossification that occurs around the age of 25, the pelvic outlet and inlet open slightly. This widening will also widen the femora as they are connected to the pelvis. The pelvis will still have some masculine characteristics by default but the end result will be wider hips than a normal male and closer to a cis female.

She said, “You may have heard before that gender is socially constructed, while sex is biological. But I’m here to tell you that what you’ve heard isn’t true. Sex is socially constructed too. So are you ready for the truth? Are you going to take the red pill or the blue pill?”

Three years later, I was diagnosed by my gynecologist with polycystic ovarian syndrome (PCOS), which means that my body produces hormones intermediate between “typical men” and “typical women.” What I learned from Kiki gave me context in which to understand what this meant about my body and who I am. But it’s still very hard for me to talk about. My hormones affect me in ways that are hard to see, so even most of my lovers don’t know. I can count the number of people in my personal life who know this about me on my two hands.

I picked the red pill. If you read on, you can take the red pill too.

The problem with calling sex “biological” is that biology is complicated. Hardly anything in biology fits into two neat categories like “male” and “female.” To give you an idea of how complicated sexual development really is, let’s go to the very beginning. How do sexual characteristics develop in a human embryo?READ ARTICLE

Australian researchers have identified a significant link between a gene involved in testosterone action and male-to-female transsexualism.

DNA analysis from 112 male-to-female transsexual volunteers showed they were more likely to have a longer version of the androgen receptor gene.

The genetic difference may cause weaker testosterone signals, the team reported in Biological Psychiatry.

However, other genes are also likely to play a part, they stressed. Increasingly, biological factors are being implicated in gender identity.

One study has shown that certain brain structures in male-to-female transsexual people are more "female like".

In the latest study, researchers looked for potential differences in three genes known to be involved in sex development - coding for the androgen receptor, the oestrogen receptor and an enzyme which converts testosterone to oestrogen.

Comparison of the DNA from the male to female transsexual participants with 258 controls showed a significant link with a long version of the androgen receptor gene and transsexualism.READ ARTICLE

Dr Chettawut did my surgery over two years ago. He is very experienced. Recently more trans girls have been able to secure SRS here in the America using insurance. While I was envious because they were able to save money, I am happy I went to Dr Chettawut who has done thousands.

Two of my friends commented on problems they had with their SRS by American surgeons. This is a serious operation and you definitely need an experienced surgeon with a good track record. Of course things can happen with an experienced surgeon, but your chances are so much better. Always research the track record of your surgeon and get recommendations. Very best wishes to all my friends...

This is the big question that is faced by anyone who is or who knows a Transsexual. Because of a number of recent discoveries the balance has been tipped toward nature. There is now evidence that the “Gender Identity Dysphoria” (GOD) has it’s roots in prenatal biology (nature) and not in psychology (nurture).

Transsexual Brain Development

Like the normal male embryo, the male to female Transsexual brain starts out female. Then between the 8th and 24th weeks, the ‘XY’ chromosomes introduce testosterone hormonal changes, but the hormonal washes as faulty. They are either insufficient or ill timed. When this happens, the fetus develops a male body. However, some of the default (original) female brain processes remain intact. Thus, the brain’s gender identity remain intact. Thus, the brains gender identity remains female. This means that Transsexual males whose process of brain masculinization was incomplete, Their default female brains still function. The degree of arrested development can vary. The orgininal brain circuitry that was missed in the masculinizing process provides a continuing feminine influence. This explains why many Transsexuals, biological males know, from as early as 3 years old, that they are actually members of the opposite sex.

How does the FtM Transsexual brain develop?

Like the normal female embryo, the female to male Transsexual fetus starts out as a normal female. Then a problem occurs somewhere between the 8th and 24th week. Even though the ‘XX’ chromosomes have ordered no hormonal washes to take place, testosterone is still introduced. For example: An errant fetal adrenal glad causes testosterone to be produced in great quantities. The fetus is washed with testosterone, against chromosomal orders. The fetal body remains female. However, if the errant wash is strong enough, the female fetus brain is re-wired to think as male. This explains why many Transsexuals, biological males know, from as early as 3 years old, that they are actually members of the opposite sex.

What is the job of the ‘XX’ and ‘XY’ chromosomes?

It seems that one of the jobs of the ‘XX’ and ‘XY’ chromosomes is to govern the introduction of testosterone into the womb. However, chromosomal influence is limited by the many glitches that can happen during the fetal growth process. This is why each human being possesses a unique mixture of male and female traits. Some of these mixes (eg: Transsexualism) make the individuals who have them significantly different from society’s expectations. This causes these people much confusion and suffering. Indeed, there are, in our world, many males who have ‘XX’ chromosomes and many females who have ‘XY’ chromosomes.

Being Transsexual is not a choice

What can be known about Transsexuals?

Transsexualism does not rise from being exposed, in childhood to the clother, toys, activities, and goals of the opposite sex. Nor are Transsexuals; sex addicts, morally corrupt or mentally ill. Transsexuals are simply people who have the body of one sex and the brain wiring of the opposite sex.READ ARTICLE

Almost all transsexuals notice significant changes in their body and facial hair as a result of hormone therapy, but with a wide variation in results. Some may only notice a slight lessening of hair after two years, or (like the author) they may be fortunate and find entire regions of their body clear of hair. Therefore it is vital that as you read these reports, you understand that your results may not align with the results which are discussed.TranswomenOne study with good management of the test subjects and controls examined the change in body hair and facial hair for transsexual women and men. There were 21 transwomen (all Caucasian, from age 20-44) who underwent an assessment of their body and facial hair density, growth rate, and diameter. All subjects were tested before starting hormone therapy, and at 4-month intervals up to one year from the start of hormones. All subjects were monitored on their cheek and upper abdomen. Over the 12-month period transwomen saw significant decreases in hair growth rates on their cheek and abdomen, with a mean reduction of 29% on their cheek and 50% on their upper abdomen. Hair density (hairs per square inch) decreased by 44% on their cheek and 50% on their upper abdomen. Hair diameter decreased by 20% on their cheek and 45% on their upper abdomen. Most of the changes were gradual over the 12-month period. (Giltay)TransmenIn the study by Giltay and Gooren there were 17 transmen (all white, from age 18-37) who underwent an assessment of their body and facial hair density, growth rate, and diameter. All subjects were tested before starting hormone therapy, and at 4-month intervals up to one year from the start of hormones. All subjects were monitored on their cheek and upper abdomen. Over the 12-month period transmen saw significant increases in hair growth rates on their cheek and abdomen. Here the results are somewhat skewed, as essentially no hair other than fine vellus hair existed on the cheeks and upper abdomen of the transmen prior to hormone therapy. Hair growth and density on the cheeks of transmen achieved the same levels as those of genetic males within 12 months, although the hair diameter was only 50% of that of a genetic male. Upper abdomen hair achieved a similar growth rate and density as that of genetic males, but hair diameter was about 40% of that of a genetic male. Hair growth rate rapidly accelerated in the first 4 months, but hair density and diameter increased more gradually over the 12-month period. (Giltay)READ ARTICLE

CHICAGO — Cross-sex hormone treatment of transgender adults leads to very few long-term side effects, according to the authors of the largest study to date to examine this issue.

More than 2000 patients from 15 US and European centers participated in the retrospective study, called Comorbidity and Side Effects of Cross-Sex Hormone Treatment in Transsexual Subjects, and nearly 1600 received at least 1 year of follow-up, the authors reported.

"Our results are very reassuring," principal investigator Henk Asscheman, MD, PhD, who heads HAJAP, his clinical research company in Amsterdam, the Netherlands, told Medscape Medical News. "There are mostly minor side effects and no new [adverse events] observed in this large population."

The primary serious side effect, venous thromboembolism, occurred in 1% of persons undergoing male-to-female (MTF) transgender transition and was due to estrogen treatment.

Among the 1596 adults who completed follow-up, 1073 were MTF and 523 were female to male (FTM). The MTF group had a mean follow-up of 5.6 years and a mean age of 35.0 years, and on average, the FTM group had a follow-up of 4.5 years and age of 27.5 years.

More than 70% of the MTF group received cyproterone acetate (in Europe) or spironolactone, as an antiandrogen, in addition to estrogen treatment, he noted.

Among FTM subjects, more than 90% received intramuscular or topical (gel) testosterone administration.READ ARTICLE

SAN FRANCISCO [April 9, 2013]: California’s Department of Managed Health Care (DMHC) has issued guidance clarifying the obligations of California’s health plans under the Insurance Gender Nondiscrimination Act (see below) In a groundbreaking directive to health plans, the DMHC confirmed that California’s Insurance Non-Discrimination Act of 2006, authored by former Assemblymember Paul Koretz, guarantees all people the right to access coverage for medically necessary care regardless of their gender identity or gender expression. The directive also provides that patients who are denied coverage can appeal the decision for review by the Department.

Transgender Law Center applauds the DMHC, Governor Jerry Brown, Insurance Commissioner Dave Jones, the Assembly Speaker John A. Pérez, and the Legislative LGBT Caucus for their commitment to ending discriminatory insurance exclusions that limit access to medically necessary care for transgender patients.Speaker Pérez said,“This is an important step in protecting the health of all Californians, including transgender individuals. No Californian should be denied care and treatment because of their gender identity or expression. Implementation of California’s Insurance Gender Nondiscrimination Act (IGNA) is a simple matter of fairness and equality in health care. I commend the Department of Managed Health Care for issuing its Director’s Letter reminding health care service plans of their obligation to comply with IGNA.”

“This one letter will save lives,” said Masen Davis, Executive Director of Transgender Law Center. “For years, transgender Californians have been denied coverage of basic care merely because of who we are. Discriminatory insurance exclusions put transgender people and our families at risk for health problems and financial hardship. Now we can finally get the care we need.”

The DMHC directive applies to HMOs and PPOs regulated by the Department of Managed Health Care. In 2012, the Department of Insurance issued non-discrimination regulations with similar protections for health insurance regulated by the Department of Insurance. Combined, this means that all California health plans and insurers cannot arbitrarily deny medically necessary services provided to other policy holders or members simply because the patient is transgender.

The newly issued DMHC letter instructs health plans to revise current plan documents to remove exclusions and limitations related to gender transition. For transgender people, how and when they transition is typically a private decision made with their doctor. The American Medical Association, American Psychological Association, American Psychiatric Association, and the American Academy of Family Physicians have all deemed transition-related care to be medically necessary for transgender patients.

A 2008 study conducted by Transgender Law Center found that an alarmingly high rate of transgender patients were denied coverage for essential health care. 15% were outright denied gender-specific care such as pap-smears or prostate exams just because they were transgender.

Individuals with questions about today’s announcement or other questions about their health coverage should contact the Department of Managed Health Care’s Help Center at 1-888-466-2219 / www.HealthHelp.ca.gov.

Transgender Law Center works to change law, policy, and attitudes so that all people can live safely, authentically, and free from discrimination regardless of their gender identity or expression. http://www.transgenderlawcenter.org

This is a huge area covering everything from clothes and cosmetic application to social behaviors in the restroom. For example, what to do if someone looks at you in the ladies? Initially, I smiled at them momentarily and looked away to not challenge with a direct stare and proceed to a stall or stand in line. Now there is no issue, either because it is an unconscious behavior or that I look confident and friendly.

Very surprising to me, nobody cares about my voice which is not fully "transitioned" yet. So I suspect many know I am trans, but they like my presentation and social behaviors. I am happy more folks like me than before particularly among younger and middle-aged people.

Fortunately, I didn't need facial surgery because I generally fit within normal female variation. Some are very concerned about their face, but given normal variation, I suspect mine is "good enough". I discovered I could do things with cosmetics eliminating any need or desire for facial surgery. I often thought about making my chin a bit more triangular or less square, but it is basically OK, so I left it alone.

Articles I read suggested that women smile more than men. Perhaps its a way of dispelling tension, but as a guy, excessive smiling is suspect or perhaps a sign of weakness or intimidation. Years earlier I had been a trumpet player and with hours of practice, I developed different lip muscles. Some folks have an incision on the inside of the upper lip to slightly expose top teeth. Believe it or not, I prefer to avoid surgery when possible, but I've obviously had my share. So, I practiced exercising facial muscles and those in my upper lip and now I can smile with exposed upper teeth easily.

Along the way I read about all manner of facial surgery, along with top and bottom surgery. Now I am very happy with what I did and what I did not do. I read enough bibliographical articles and books to understand that many face similar concerns. "Know yourself" and understanding the choices is critical. Nobody understands you better than you do regardless of certifications or pretense.

I hope all of this helps. People vote on me based on "the preponderance of evidence"
(LOL, I love that line) but it is true. If you miss a couple minor things they will ignore them based on other factors... ESPECIALLY if they personally like you or smile a lot.
Here is a fine example...

Trans-Mayor

Stu doesn't pass that well, an understatement, but is well accepted in this rural community--in fact, she is the Mayor.On Election Day 2012, a transgender Oregonian drew national attention for the second time by winning a fifth term as Mayor of Silverton, Oregon.

Hormonal therapy for transsexual patients is safe and effective, a multicenter European study indicates. The results will be presented Saturday at The Endocrine Society's 95th Annual Meeting in San Francisco.Transsexual individuals who seek treatment may feel as though they were born the wrong gender. Surgical and hormonal therapies are available to help these people change their external characteristics to match their internal image of themselves.Hormonal therapy involves large doses of male or female sex hormones, which has led to concern about its health effects. This study found that short-term hormonal therapy for transsexualism is effective and safe, with few side effects."Although transsexualism remains a rare diagnosis, the number of trans persons seeking hormonal or surgical treatment has drastically increased in recent years, making a detailed multicenter description on the effects of cross-sex hormonal treatment timely," said study lead author Katrien Wierckx, MD, an endocrinologist at Ghent University Hospital in Belgium. "Our study gives valuable information about the effects of drastic changes in sex steroids on glucose and lipid metabolism, cardiovascular and bone health, so that we can inform our future clients, their families and other caregivers more accurately on the desired effects, side effects and adverse events of cross-sex hormonal treatment."The effects reported by males transitioning to female in this study included breast tenderness, hot flashes, emotional behavior, and decreased interest in sexual activity. In addition, male-to-female transsexuals had significantly increased fat tissue, and decreases in lean tissue and muscle.Among females who were transitioning to male gender, effects included increased interest in sexual desire, greater variation in tone of voice. This group also exhibited significantly more acne and body hair, as well as increases in lean tissue and muscle, and decreases in fat tissue. No serious complications occurred in either group.This multicenter study included 45 transsexual men and 42 transsexual women at four European centers in Ghent, Oslo, Amsterdam and Florence that specialize in transgender treatment.Female-to-male transsexuals received a form of the male sex hormone testosterone. Male-to-female transsexuals received anti-androgen treatment in combination with a form of estrogen, which is the principal female sex hormone. Treatment was for 12 months.Throughout the study, investigators measured participants' waist-to-hip ratio, blood pressure, and the percentages of fat and lean tissue mass. Follow-up was one year.In addition to demonstrating the safety of hormonal treatment for transgender people, these findings can also help clarify its safety for other indications, according to Wierckx."Studies in transsexual persons generate knowledge on the similarities and differences between men and women," she said. "This is why some of our findings can be extrapolated to other, more common conditions that are associated with changes in sex steroid hormones, such as hyperandrogenism in women, for example, polycystic ovarian syndrome; or androgen deprivation therapy in men, for example, when undergoing prostate cancer treatment, or treatment for sex offenders."The Special Research Fund of the Ghent University, the Flemish Research Fund, and the European Society of Sexual Medicine funded the study.READ ARTICLE

A study, published last year and conducted at the Laboratory of Neuro Imaging at UCLA School of Medicine, explored the extent to which brain anatomy is associated with gender identity. "The degree to which one identifies as male or female has a profound impact on one's life," the authors wrote. "Yet, there is a limited understanding of what contributes to this important characteristic termed gender identity."Many who live at variance to their birth gender as well as many in the scientific field would heartily agree.

Historical Background

In 1910, German physician Magnus Hirschfeld coined the term "transvestites" to describe individuals who are more comfortable in clothing of the opposite gender. Hirschfeld's interest in this study population was not purely professional; he himself identified as a transvestite in addition to being gay. He believed that sexual orientation was a naturally occurring trait worthy of scientific inquiry, and in his many studies hefound that transvestites could be men or women and could identify as any sexual orientation. In fact, most of his participants were heterosexual. Meanwhile, many psychoanalysts during the same period, including Wilhelm Stekel, characterized transvestites as "latent homosexuals" or men who consistently denied their attraction to other men.

Years later in 1948, endocrinologist Harry Benjamin was asked by Alfred Kinsey, the biologist and most famously sexologist who in 1947 founded the Institute for Sex Research, to examine a boy who "assured to be a girl." The mother of the boy had come to him wishing for help that would assist rather than thwart her child, and Kinsey had never encountered such a case. Upon his own examination, Benjamin understood that the boy's condition was markedly different than that of transvestism.

He immediately involved psychiatrists, but they were unable to agree on a strategy for treating the boy. Eventually, Benjamin decided to administer estrogen to the boy; he used Premarin, which had been introduced in 1941. This treatment, he noted, had a calming effect. Next, he helped arrange for the mother and child to go to Germany where surgery could be performed. Hirschfeld supervised the first recorded sex reassignment surgery in Berlin sometime during 1930-1931. The earliest surgeries primarily consisted of the removal of the male sex organs, though unsuccessful uterine transplants were attempted. Although the mother of the boy ceased contact after her departure for Germany, Benjamin continued to refine his understanding of her boy's condition, and in 1954 he reprised the term "transsexualism," which had been coined by Hirschfeld in 1923. Benjamin went on to treat several hundred similar patients in a similar manner, often without accepting payment.

From early on, then, scientists have identified separate communities of people — those who wished to dress as the opposite sex and those who wished to become the opposite sex. Although a much wider spectrum of gender identities currently exists, only now can the original ideas of transvestism and transsexualism be fully explored in a scientific way. And such is the case with the researchers at the UCLA School of Medicine who hoped to pinpoint more concrete factors influencing gender identity.READ ARTICLE

Medically necessary treatments and procedures, such as those defined by the World Professional Association for Transgender Health's Standards of Care for Gender Identity Disorders, should be included in employer-provided healthcare and short-term disability coverage.

Transgender people face many forms of discrimination in the provision of health insurance. Employers, as consumers of group health insurance products, can advocate on behalf of the transgender people insured on their group health insurance plans. Employers should work with their insurance carriers or administrators to remove transgender exclusions and provide comprehensive transgender-inclusive insurance coverage.

The American Medical Association joined the movement to end discrimination in health insurance for transgender people by passing the following resolution at their annual meeting in June 2008:

"RESOLVED, That our American Medical Association support public and private health insurance coverage for treatment of gender identity disorder as recommended by a physician."

This is a major life altering step and of course you want to be sure. There are many articles available and more psychologists are becoming familiar with gender dysphoria. Know yourself is the best advise I can give. This step can affect your ability to earn a living and that is critical to having a pleasant life.

Make sure you have the money to finance yourself and any surgery you need. Some insurance companies are beginning to include surgery, doctor visits and hormones in their plan, but the majority do not at this time. I went to Bangkok where there are skilled surgeons a a more affordable price.

The first step is to make sure you have a trade, skill or college degrees that will assure your income. These make you more marketable and assures your income. It also improves social acceptance. Nobody wants to be a social outcast or resort to the sex trade to survive. First things first.Best wishes to all... Plan this with care.

Yes, there is. Indeed, there are a multitude of options open to you, and in certain ways you can consider yourself spoilt for choices. The real issue is making certain you truly know what you want. Once you know that, I assure you that you can actually, truly achieve it....depending on a few factors which I will explain.For the classic, 'true' transsexual, such as your author, the future is very clean cut and straightforward. If you are less defined, if you are unsure or unclear, if your issues are not beyond question, then the multitude of choices become worth examination. Let us take this step by step.

A classic, or 'true' transsexual follows a fairly predictable pattern, with a rather predictable and common life story. The basic cookie cutter version is easily summarized.

The classic transsexual is aware of gender conflict at a very early stage in life, usually somewhere around the age of five. The gender issue causes problems throughout life, because the transsexual cannot entirely suppress or deny the truth of their identity altogether, despite social pressure to do so. As time goes on, the agony of gender dysphoria, and a life of misery and self-denial, becomes unendurable and something must be done about it, either to correct it, or to permanently stop the suffering. For the latter group, the answer is too commonly suicide, but for the former, the answer is very standardized: hormones, followed usually by surgery.READ ARTICLE

As you were growing up, how did you know you were a girl or a boy? Was it because you had a vagina or a penis? Or was it something more than your physiology? Some people feel that their minds and bodies don’t quite match up. This feeling is commonly known as transsexualism — a type of gender identity disorder. Transsexuals are dissatisfied with their sexual identity, body characteristics or gender role. They wish to live as the opposite gender and may transform their bodies through gender reassignment surgery — a collection of procedures commonly known as a “sex change.”

Gender identity struggles usually begin in early childhood but have been identified in people of all ages. A biologically born man who identifies as a woman is known as transwoman, or transsexual woman. Labels like cross-dresser, transvestite, drag queen or drag king are not interchangeable with transsexual. However, transgender is used as a general, non-medical term to describe anyone with any type of gender identity issue.

It’s estimated that one in 11,900 males are transsexual adults [source: WPATH Standards of Care]. Lynn Conway, a professor emerita at the University of Michigan, estimates that one in 2,500 United States citizens has undergone male-to-female gender reassignment surgery [source: Advocate].

So you have decided to transition from one gender to another.
What next?
Have you decided how far you are going to go? Do you want hormones?

Are you going to get gender reassignment surgery and if so, where can you get the proper services? You need to plan out your transsexual road map, a plan of who, what, where, when and how. A plan that will help guide you through the days to come. Have patience, persistence and proper preparation and you will glide through your transition to become the beautiful butterfly we all know you are!

I just read this interesting viewpoint.."Being trans* is kind of like a crayon coming out of the factory with the wrong wrapper. It's a blue (or pink) crayon, and it's wrapper says pink (or blue), but it's true colors are on the inside. When someone opens the box, some will return it to the box as if it were wrong to use, some will break it in half, and some will cherish it because it's "one-of-a-kind". But it's those who choose to remove the wrong wrapper and replace it with the correct one, that truly make a difference. Be true to your colors..."

"It isn't easy being green", Kermit the Frog, but green we are so understand yourself because if you don't nobody else will regardless of professional certifications. You are the only one who knows, hopefully, and it is your job to sort it out because others can only contribute ideas.

If you need surgery, you will need a psychiatrist to give you a letter. Make sure you get someone who actually knows about transgender issues, because many do not. A knowledgeable, understanding person can actually help you understand yourself, but again this is mostly based on what they learned elsewhere.

MY SUGGESTION.. read a lot about everything as many experiences are similar. On the other hand, it isn't easy distinguishing the various influences that affect one's life. Know about the various medical options and surgeries... and if you choose surgery, pick someone with an excellent reputation.

There are many internet resources including mine...
Very best wishes, I wish you well!!!
BILLIE RENE'S BLOG

Truth be told... I can't pass on the phone and guess what, it doesn't matter, But I have raised the pitch and reduced resonance with practice so some cisgendered women are deeper than me and I speak more quietly. As women get older their voices deepen some because of smoking. Some cisgender girls tell me they are "Sir'd" too. When people see me they may recognize the obvious depending on their "transdar". I was a guy and now I am not. No problem. It may actually promotes understanding of transpeople.

When I go to the store, I am very well received. The other day one person gave me a big hug. WOW, I have so many friends now. I never expected this. SOooo, I guess voice is one more thing I don't need to think about. Friendly attitude and presentation are important for me.
THE ARTICLE FOLLOWS...

You can be very passable in your appearance, but if you speak in a masculine voice you've just outed yourself . . .

It amazes me how many transsexual women speak in a masculine-sounding voice, even post-ops.
They'll spend thousands on hormones, electrolysis, surgery, etc. but won't make the effort to retrain their voices. If you don't mind getting sir'd on the phone, or even in public, go ahead and talk like a man. But if you want to pass as a woman your voice is important.

Another reason to speak in a female voice is, whether we like it or not, we're all ambassadors for the trans community. People will often base their opinions of us on first impressions. If you speak in a male voice, not only will there be incongruity between your voice and appearance, but it will tend to make people relate to us more as drag queens and crossdressers—an image we need to get away from.

Any male voice can be retrained. Don't be discouraged if you're starting with a baritone! For proof that your voice can be changed, try talking in falsetto. Obviously, it sounds silly and I don't recommend talking in falsetto, but it shows even the deepest voice can be raised.

Just like your walk, you're unlearning years of doing something in a masculine way. You're retraining your throat muscles. It was two-and-half months before I started getting ma'am on the phone and it may take a year, or more, before your voice sounds good in all situations, like yelling.

Will hormones make your voice higher? Unless you started HRT at the onset of, or early, puberty before your voice changed, hormones will have no effect on pitch, though estrogen will tend to soften the voice.

What about vocal surgery? That's an option and can take the worry out of whether you'll get clocked when you speak. I know three trans women who've had vocal surgery. Two sounded good and one didn't, she sounded raspy (I guess two out of three ain't bad). As with most surgery, the outcome of voice surgery isn't certain. Explore your options and educate yourself about vocal surgery before deciding. If you don't want surgery some voice training is usually required.READ ARTICLE